ABSTRACT

Objective

To identify interventions that facilitate sustainable jobs and have a positive impact on the health of workers in health sector workplaces.

Methods

This overview utilized systematic review methods to synthesize evidence from multiple systematic reviews and economic evaluations. A comprehensive search was conducted based on a predefined protocol, including specific inclusion criteria. To be classified as “sustainable,” interventions needed to aim (explicitly or implicitly) to 1) have a positive impact on at least two key dimensions of the integrated framework for sustainable development and 2) include measures of health impact. Only interventions conducted in, or applicable to, health sector workplaces were included.

Results

Fourteen systematic reviews and no economic evaluations met the inclusion criteria for the overview. The interventions that had a positive impact on health included 1) enforcement of occupational health and safety regulations; 2) use of the “degree of experience rating” feature of workers’ compensation; 3) provision of flexible working arrangements that increase worker control and choice; 4) implementation of certain organizational changes to shift work schedules; and 5) use of some employee participation schemes. Interventions with negative impacts on health included 1) downsizing/restructuring; 2) temporary and insecure work arrangements; 3) outsourcing/home-based work arrangements; and 4) some forms of task restructuring.

Conclusions

What is needed now is careful implementation, in health sector workplaces, of interventions likely to have positive impacts, but with careful evaluation of their effects including possible adverse impacts. Well-evaluated implementation of the interventions (including those at the pilot-study stage) will contribute to the evidence base and inform future action. Interventions with negative health impacts should be withdrawn from practice (through regulation, where possible). If use of these interventions is necessary, for other reasons, considerable care should be taken to ensure an appropriate balance between business needs and human health and well-being.

Key words
Sustainable development; employment; workers; health; review; systematic; Americas

ABSTRACT

Objetivo

Determinar las intervenciones que facilitan el empleo sostenible y tienen un impacto positivo en la salud de los trabajadores del sector de la salud.

Métodos

En esta síntesis se utilizaron métodos de revisión sistemática a fin de resumir los datos de múltiples revisiones sistemáticas y evaluaciones económicas. Se realizó una amplia búsqueda de acuerdo con un protocolo predefinido, que incluyó criterios de inclusión específicos. Para que se clasificaran como “sostenibles” las intervenciones debían estar dirigidas (explícitamente o implícitamente) a: 1) tener una repercusión positiva en al menos dos dimensiones clave del marco integrado para el desarrollo sostenible y 2) incluir mediciones de los efectos de salud. Solo fueron incluidas las intervenciones realizadas en los lugares de trabajo del sector de la salud, o aplicables a este entorno.

Resultados

Catorce revisiones sistemáticas reunieron los criterios de inclusión en la síntesis, pero ninguna evaluación económica los reunió. Las intervenciones que tuvieron un impacto positivo en la salud fueron, entre otras: 1) cumplimiento de los reglamentos en materia de salud y seguridad ocupacionales; 2) inclusión del factor de “ajuste por frecuencia siniestral” del sistema de aseguramiento de los riesgos del trabajo; 3) introducción de modalidades de trabajo flexibles que aumentan el control y la elección de los trabajadores; 4) adopción de determinados cambios organizativos para modificar los horarios de trabajo y 5) establecimiento de algún mecanismo de participación de los empleados. Las intervenciones que tuvieron una repercusión negativa en la salud incluyeron 1) reestructuración y recortes; 2) contrato de trabajo temporal y precario; 3) contratación externa y trabajo desde el domicilio y 4) algunas formas de reestructuración de tareas.

Conclusiones

Es necesario ejecutar cuidadosamente en los lugares de trabajo del sector de la salud las intervenciones con más probabilidades de tener un impacto positivo y evaluar cuidadosamente la ejecución de dichas intervenciones, incluidos los posibles efectos adversos. La ejecución apropiadamente evaluada de las intervenciones (incluidas aquellas en la etapa de prueba piloto) contribuirá a ampliar la base empírica y sustentar la acción futura. Las intervenciones que repercuten negativamente en la salud deberían ser eliminadas de la práctica (en lo posible, mediante la reglamentación). Si por alguna razón esas intervenciones fueran necesarias, se debería tener el suficiente cuidado de garantizar un equilibrio adecuado entre las necesidades institucionales y la salud y el bienestar humanos.

Palabras clave
Desarrollo sostenible; empleo; trabajadores; salud; revisión; Américas

Sustainable development is generally thought of as development that balances social, environmental, and economic objectives or needs. It has been defined as “development which meets the needs of the present without compromising the ability of future generations to meet their own needs” (¹1 World Commission on Environment and Development. Our common future (Brundtland Report). Oxford: Oxford University Press; 1987. 400 pp., p. 41). Prior to the 2012 United Nations (UN) Conference on Sustainable Development held in Rio de Janeiro (commonly referred to as “Rio+20”), the UN System Task Team working on the Post-2015 UN Development Agenda proposed an integrated framework for sustainable development (²2 United Nations System Task Team. Realizing the future we want for all. Report of the UN System Task Team on the Post-2015 Development Agenda. New York: UN; 2012. Available from: http://www.un.org/en/development/desa/policy/untaskteam_undf/report.shtml
http://www.un.org/en/development/desa/po... , p. 24). The framework informed the 2030 Agenda for Sustainable Development (“Agenda 2030”) and the 17 Sustainable Development Goals (SDGs) agreed upon by the UN in September 2015, designed to build on the Millennium Development Goals that expired in 2015 (³3 United Nations General Assembly. Transforming our world: the 2030 agenda for sustainable development. Resolution adopted by the General Assembly on 25 September 2015. New York: UN; 2015. (A/RES/70/1). Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld
https://sustainabledevelopment.un.org/po... ). The framework includes the core values of human rights, equality, and sustainability, plus four key dimensions: 1) inclusive social development; 2) inclusive economic development; 3) environmental sustainability; and 4) peace and security.

“Ensuring decent work and productive employment” is a key component of the inclusive economic development dimension of the framework. Following from this, decent work and productive employment were included as part of Goal 8 of the 17 SDGs (“Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all”), to be achieved by 2030 (³3 United Nations General Assembly. Transforming our world: the 2030 agenda for sustainable development. Resolution adopted by the General Assembly on 25 September 2015. New York: UN; 2015. (A/RES/70/1). Available from: https://sustainabledevelopment.un.org/post2015/transformingourworld
https://sustainabledevelopment.un.org/po... ). Furthermore, the concept of “decent work,” as defined by the International Labour Organization (ILO) and endorsed by the international community (⁴4 World Health Organization. Health in the green economy—occupational health. Initial findings from a WHO Expert Consultation, 17–18 May 2012, Rio de Janeiro. Geneva: WHO; 2012. Available from: http://www.who.int/hia/green_economy/en/
http://www.who.int/hia/green_economy/en/... ), and the four strategic pillars of the ILO Decent Work Agenda (⁵5 International Labour Organization. Decent work [Internet]. Geneva: ILO; 2013. Available from: http://www.ilo.org/global/topics/decent-work/lang--en/index.htm Accessed on 8 November 2013.
http://www.ilo.org/global/topics/decent-... ), are consistent with the intent of sustainable development represented in the integrated framework and are crucial for human health (2, p. 24).

Protecting human health is a key aspect of the “inclusive social development” dimension of the integrated framework for sustainable development and an outcome of, and precondition for, the other three dimensions (inclusive economic development, environmental sustainability, and peace and security). Therefore, the health sector has a significant role in producing evidence on the health impact of the sustainable development strategies and in encouraging intersectoral action to protect human health (⁶6 Pan American Health Organization. Health, environment and sustainable development: towards the future we want. A collection of texts based on the PAHO Seminar Series ‘Towards Rio+20’ that occurred in the period between 8 February and 13 June 2012. Washington: PAHO; 2013. Available from: http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=22825&
http://www.paho.org/hq/index.php?option=... ).

This overview of the systematic review and economic evaluation literature (along with three other, related overviews) was carried out by the Pan American Health Organization (PAHO) to inform the development of the new SDGs, including, but not limited to, the provision of evidence for its member states on the possible health impact(s) of policies and programs in non-health sectors (e.g., employment).

The objective of this overview was to use the best available evidence to answer the following question: “What are the interventions that facilitate sustainable jobs and have a positive impact on workers’ health in health sector workplaces?” Sub-questions included: 1) “What is their impact on health inequalities?”; 2) “What evidence is there for their cost-effectiveness?”; and 3) “Which dimensions of the integrated framework are affected by the intervention, and how?”

Interventions that aimed (explicitly or implicitly) to have a positive impact on at least two dimensions of the integrated framework for sustainable development were classified as interventions that could facilitate sustainable jobs. Examples of interventions that fit these criteria included those related to precarious employment, such as temporary work, outsourcing, home-based work, and downsizing, which can have both health and economic impacts (⁷7 Quinlan M, Mayhew C, Bohle P. The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv. 2001;31(2):335–414.). A healthy workforce is a prerequisite for social and economic development and for productivity (⁸8 World Health Organization. Health indicators of sustainable jobs in the context of the Rio+20 UN Conference on Sustainable Development. Initial findings from a WHO Expert Consultation, 17–18 May 2012, Rio de Janeiro. Geneva: WHO; 2012. Available from: http://www.who.int/hia/green_economy/indicators_jobs.pdf
http://www.who.int/hia/green_economy/ind... ). Due to the large volume of literature available, this overview focused on interventions conducted in or applicable to health sector workplaces.

MATERIALS AND METHODS

This overview 1) used systematic review methodology to locate and evaluate published systematic reviews of interventions and 2) adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (⁹9 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.). A systematic review protocol was written and registered prior to undertaking the searches (¹⁰10 Haby M, Chapman E, Clark R, Galvão L. Interventions that have a positive impact on worker’s health and facilitate sustainable development: an overview of systematic reviews [protocol]. PROSPERO. 2014;CRD42014008944. Available from: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014008944
http://www.crd.york.ac.uk/PROSPERO/displ... ).

Inclusion criteria for studies

Studies were selected based on the inclusion criteria described below.

Types of studies

Studies included systematic reviews of studies of effectiveness, including reviews of randomized controlled trials (individuals or clusters); quasi-randomized controlled trials; controlled before-and-after studies; interrupted time series; and analytic observational studies (cohort, case-control, and cross-sectional studies). Economic evaluations (cost-effectiveness, cost–utility, and/or cost–benefit) and systematic reviews of economic evaluations were included.

Types of participants

Study participants included individuals, groups, communities, countries, or regions. Studies from both developed and developing countries were included.

Types of interventions

Interventions included programs, policies, strategies, legislation, and other courses of action to promote and/or provide fair terms of employment and decent working conditions. To be classified as “sustainable,” interventions needed to aim (explicitly or implicitly) to have a positive impact on at least two dimensions of the integrated framework for sustainable development (e.g., inclusive economic development and inclusive social development (which includes health) or environmental sustainability and inclusive economic development but where impact on health was also measured). Health promotion interventions delivered by the health sector were excluded unless they specifically aimed to improve the terms of employment of workers and/or working conditions. Though not part of the original protocol, after the initial search and review of titles/abstracts, the funders and authors of this overview agreed to focus on interventions conducted in or applicable to health sector workplaces. This decision was made due to the large quantity of potentially relevant systematic reviews found in the literature search, which, if all included, would have made the overview unmanageable given time and budget constraints.

Types of comparisons

Comparisons included “no intervention,” “another intervention,” or “current practice.”

Types of outcome measures

Publications in English, Spanish, or Portuguese and published in the last 17 years (from 1997 to the day of the search) were included. Both grey and peer-reviewed literature were sought and included.

Sources of systematic reviews and economic evaluations

A comprehensive search of 17 databases and 10 websites was conducted. The databases searched for systematic reviews were PubMed; EMBASE^®; CINAHL; ASSIA; PsycINFO; ScienceDirect; LILACS; SciELO; GreenFILE; The Cochrane Library (including Cochrane Reviews, the Database of Abstracts of Reviews of Effects (DARE), and the Health Technology Assessment Database (HTA)); The Campbell Library; and Health-Evidence^™.

The websites that were searched included specialized sources for systematic reviews and other websites: Effective Public Health Practice Project, Evidence for Policy and Practice Information and Coordinating Centre (EPPI-Centre), National Institute for Health and Clinical Excellence (NICE), The Community Guide (Centers for Disease Control and Prevention (CDC)), International Initiative for Impact Evaluation (“3ie”), the Sax Institute Evidence Check Library (for rapid reviews), WHO (including the library database (WHOLIS) and the Institutional Repository for Information Sharing (IRIS)), Google, and the ILO. The reference list of included systematic reviews was also searched.

For economic evaluations, two specialized databases were searched: EconLit (American Economic Association abstracting database) and the NHS Economic Evaluation Database (NHS EED).

Search strategy

Searches were conducted from 14 to 16 January 2014. Databases were searched using the key words shown in Table 1, searched for in the title and abstract, except when noted otherwise. Key word areas were joined using ‘AND’. Searches were limited to human research with a publication date between 1 January 1997 and the day of the search. A sample search strategy for EMBASE using the Ovid interface (Ovid Technologies, New York, NY, United States) is also shown in Table 1. Results were downloaded into the EndNote reference management program (version X7) (Thomson Reuters, New York, NY) and duplicates removed.

Screening, data collection, and analysis

Searches were conducted and screened according to the selection criteria by one review author (MH). The full text of any potentially relevant papers was retrieved for closer examination. The inclusion criteria were applied to the papers independently by two reviewers (MH and RC). Disagreements regarding eligibility of studies were resolved by discussion and consensus. All studies that initially appeared to meet the inclusion criteria but on inspection of the full-text paper did not were listed in a table (“Characteristics of excluded systematic reviews”) with the reasons for their exclusion. One reviewer (MH) extracted all relevant data from the included papers using a standard form. A second reviewer (RC) verified the extracted data. Differences were resolved by discussion and consensus. Data/information extracted from systematic reviews included objectives, inclusion criteria for the systematic review, date of search, number of studies included, country or region of included studies, details of interventions studied, the integrated framework dimensions targeted by the individual studies (implicitly or explicitly), summary of findings in relation to health, impact on any of the key dimensions of sustainable development, impact on health inequalities, impact on secondary outcomes, impact on human rights, limitations of the systematic review, research gaps, and critical success factors for the interventions.

Findings from the included publications and their methodological quality were synthesized using tables and a narrative summary. Meta-analysis was not possible because included studies were heterogeneous in terms of the type of intervention studied and outcomes measured.

Assessment of methodological quality

The methodological quality of included systematic reviews was assessed independently by two reviewers using AMSTAR: A MeaSurement Tool to Assess Reviews (¹¹11 Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007;7:10.). For this overview, reviews that achieved AMSTAR scores of 8 to 11 were considered “high-quality”; scores of 4 to 7 “medium-quality”; and scores of 0 to 3 “low-quality”. These cutoffs are commonly used in Cochrane Collaboration overviews. The review quality assessment was used to interpret the results of reviews when synthesized in this overview and in the formulation of conclusions.

RESULTS

Search results

Fourteen systematic reviews (and no economic evaluations) met the inclusion criteria for the overview (7, 12–24). The selection process for systematic reviews and the number of papers found at each stage are shown in Figure 1. Eleven papers were excluded at the full-text stage because they were not systematic reviews (n = 3), did not include health sector workers (n = 1), did not look at interventions related to sustainable jobs in health sector workplaces (n = 4), and/or did not measure (or aim to measure) the relevant health outcomes (n = 7) (Supplementary Material File 1, Table A1a). One additional systematic review was located through the search of the reference list of included systematic reviews (⁷7 Quinlan M, Mayhew C, Bohle P. The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv. 2001;31(2):335–414.), one through communication with Professor Clare Bambra (Durham University, United Kingdom) regarding her included systematic reviews (¹⁶16 Joyce K, Pabayo R, Critchley JA, Bambra C. Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database Syst Rev. 2010;2: CD008009.), and one through a search by the funders (¹⁷17 Kim IH, Muntaner C, Vahid Shahidi F, Vives A, Vanroelen C, Benach J. Welfare states, flexible employment, and health: a critical review. Health Policy. 2012;104(2):99–127.).

The selection process for economic evaluations and the number of papers found at each stage are also shown in Figure 1. After examination of the full-text papers, all four potential economic evaluations were excluded for the reasons given in Supplementary Material File 1 (Table A1b).

Characteristics of included studies and quality assessment

Interventions studied in the included systematic reviews are shown in Box 1. No systematic reviews or economic evaluations were found that looked specifically at the impact on health of 1) informal work; 2) the application of occupational health and safety (OHS) policies and programs among informal workers; 3) secure work and a living wage (one that takes into account the real and current cost of living) in both the formal and informal sectors; 4) measures that strengthen the capacity of the health sector to promote the inclusion of workers’ health in other sectors’ policies; 5) consideration of workers’ health in trade policies; 6) employment policies; 7) consideration of workers’ health in multilateral environmental agreements and mitigation strategies, environmental management systems, and plans for emergency preparedness and response; 8) addressing workers’ health in sectorial policies for different branches of economic activity, particularly those with the highest health risk; and 9) consideration of workers’ health in primary, secondary, and higher-level education and vocational training (²⁵25 Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008., ²⁶26 World Health Organization. Resolution 60.26. Workers’ health: global plan of action. Sixtieth World Health Assembly, 13–23 May 2007, Geneva, Switzerland. Geneva: WHO; 2007.).

The types of interventions studied, quality of the evidence, and impact on health are shown in Table 2. Additional details about the characteristics of the included systematic reviews can be found in Supplementary Material File 2. AMSTAR scores ranged from 3 to 10, with five systematic reviews rated as “high-quality” (scores between 8 and 11) (¹²12 Bambra C, Egan M, Thomas S, Petticrew M, Whitehead M. The psychosocial and health effects of workplace reorganisation. 2. A systematic review of task restructuring interventions. J Epidemiol Community Health. 2007;61(12):1028–37., ¹⁶16 Joyce K, Pabayo R, Critchley JA, Bambra C. Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database Syst Rev. 2010;2: CD008009., ¹⁸18 Mischke C, Verbeek Jos H, Job J, Morata TC, Alvesalo-Kuusi A, Neuvonen K, et al. Occupational safety and health enforcement tools for preventing occupational diseases and injuries. Cochrane Database Syst Rev. 2013;8:CD010183., ²⁰20 Pega F, Carter K, Blakely T, Lucas PJ. In-work tax credits for families and their impact on health status in adults. Cochrane Database Syst Rev. 2013;8: CD009963., ²⁴24 Witter S, Fretheim A, Kessy FL, Lindahl AK. Paying for performance to improve the delivery of health interventions in low- and middle-income countries. Cochrane Database Syst Rev. 2012;2:CD007899.); six rated as “medium-quality” (scores between 4 and 7) (13–15, 19, 21, 22); and three rated as “low-quality” (scores between 0 and 3) (⁷7 Quinlan M, Mayhew C, Bohle P. The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv. 2001;31(2):335–414., ¹⁷17 Kim IH, Muntaner C, Vahid Shahidi F, Vives A, Vanroelen C, Benach J. Welfare states, flexible employment, and health: a critical review. Health Policy. 2012;104(2):99–127., ²³23 Westgaard RH, Winkel J. Occupational musculoskeletal and mental health: significance of rationalization and opportunities to create sustainable production systems—a systematic review. Appl Ergon. 2011;42(2):261–96.). The AMSTAR scores are shown in Supplementary Material File 2 (Table A2a). All three systematic reviews covering precarious employment / production system rationalization were rated as low-quality, so their results should be interpreted with care.

Effectiveness

No evidence was found for teleworking, a form of flexible working. For all other interventions, evidence on the impact on health was either insufficient or mixed (Table 2). The cost-effectiveness of the included interventions is not known.

Impact on health inequalities

The impact of interventions on health inequalities is largely unknown. Five of the systematic reviews included health inequalities as explicit outcomes (12–14, 16), and another four attempted to report socioeconomic and/or gender differences (⁷7 Quinlan M, Mayhew C, Bohle P. The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv. 2001;31(2):335–414., ¹⁵15 Egan M, Bambra C, Thomas S, Petticrew M, Whitehead M, Thomson H. The psychosocial and health effects of workplace reorganisation. 1. A systematic review of organizational-level interventions that aim to increase employee control. J Epidemiol Community Health. 2007;61(11):945–54., ¹⁷17 Kim IH, Muntaner C, Vahid Shahidi F, Vives A, Vanroelen C, Benach J. Welfare states, flexible employment, and health: a critical review. Health Policy. 2012;104(2):99–127., ²⁰20 Pega F, Carter K, Blakely T, Lucas PJ. In-work tax credits for families and their impact on health status in adults. Cochrane Database Syst Rev. 2013;8: CD009963.). However, where impact on health inequalities was assessed it was done in few of the included primary studies, and the findings were mostly inconclusive. However, the results indicated that employee participation schemes might benefit lower-grade workers and those belonging to ethnic minority groups (based on one study) (¹⁵15 Egan M, Bambra C, Thomas S, Petticrew M, Whitehead M, Thomson H. The psychosocial and health effects of workplace reorganisation. 1. A systematic review of organizational-level interventions that aim to increase employee control. J Epidemiol Community Health. 2007;61(11):945–54.). For precarious employment, five out of eight studies that examined gender found that women were especially vulnerable to adverse health effects (⁷7 Quinlan M, Mayhew C, Bohle P. The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv. 2001;31(2):335–414.), while another systematic review on the same topic found more nuanced results (¹⁷17 Kim IH, Muntaner C, Vahid Shahidi F, Vives A, Vanroelen C, Benach J. Welfare states, flexible employment, and health: a critical review. Health Policy. 2012;104(2):99–127.). The fact that precarious employment can lead to poorer health is in itself evidence of employment-related health inequalities (⁷7 Quinlan M, Mayhew C, Bohle P. The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv. 2001;31(2):335–414., ¹⁷17 Kim IH, Muntaner C, Vahid Shahidi F, Vives A, Vanroelen C, Benach J. Welfare states, flexible employment, and health: a critical review. Health Policy. 2012;104(2):99–127., ²³23 Westgaard RH, Winkel J. Occupational musculoskeletal and mental health: significance of rationalization and opportunities to create sustainable production systems—a systematic review. Appl Ergon. 2011;42(2):261–96.).

Dimensions of the integrated framework for sustainable development that were affected

Given the inclusion criteria, all interventions that were studied aimed to have an impact on inclusive social development, which includes health. Most of the interventions that were reviewed also aimed to have an impact on inclusive economic development (although the economic effects of the interventions were not well assessed). OHS regulations led to an increase in workplace productivity (based on one study) (²¹21 Robson LS, Clarke JA, Cullen K, Bielecky A, Severin C, Bigelow PL, et al. The effectiveness of occupational health and safety management system interventions: a systematic review. Safety Science. 2007;45(3): 329–53.). No effect on workplace productivity was found for the use of inspections to enforce regulations (based on two studies) (¹⁸18 Mischke C, Verbeek Jos H, Job J, Morata TC, Alvesalo-Kuusi A, Neuvonen K, et al. Occupational safety and health enforcement tools for preventing occupational diseases and injuries. Cochrane Database Syst Rev. 2013;8:CD010183.). According to the reviewers, none of the interventions in the included studies had the potential to affect environmental sustainability or peace and security.

DISCUSSION

The sustainable jobs interventions conducted in or applicable to health sector workplaces that had a positive impact on health included 1) enforcement of OHS regulations; 2) use of the “degree of experience rating” feature of workers’ compensation; 3) flexible working arrangements that increase worker control and choice (e.g., gradual/partial retirement); 4) some organizational changes to shift work schedules (e.g., self-scheduling of shifts); and 5) some employee participation schemes (e.g., employee committees). Interventions with negative impacts on health included 1) downsizing/restructuring; 2) temporary and insecure (precarious) work; 3) outsourcing/home-based work; and 4) some forms of task restructuring (autonomous groups). Evidence for all other interventions studied was insufficient or mixed.

Several of the systematic reviews included in this overview supported the hypothesis that level of employee control is important in improving employee health (12, 14–16). This included “micro-level” organizational interventions that affect workers’ daily task structures (¹²12 Bambra C, Egan M, Thomas S, Petticrew M, Whitehead M. The psychosocial and health effects of workplace reorganisation. 2. A systematic review of task restructuring interventions. J Epidemiol Community Health. 2007;61(12):1028–37.); self-scheduling of shift work (¹⁴14 Bambra CL, Whitehead MM, Sowden AJ, Akers J, Petticrew MP. Shifting schedules: the health effects of reorganizing shift work. Am J Prev Med. 2008;34(5): 427–34., ¹⁶16 Joyce K, Pabayo R, Critchley JA, Bambra C. Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database Syst Rev. 2010;2: CD008009.); organizational-level interventions intended to increase employees’ opportunities to make decisions or participate in decision-making (¹⁵15 Egan M, Bambra C, Thomas S, Petticrew M, Whitehead M, Thomson H. The psychosocial and health effects of workplace reorganisation. 1. A systematic review of organizational-level interventions that aim to increase employee control. J Epidemiol Community Health. 2007;61(11):945–54.); and flexible working interventions that increase worker control and choice, such as self-scheduling of shift work or gradual/partial retirement (¹⁶16 Joyce K, Pabayo R, Critchley JA, Bambra C. Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database Syst Rev. 2010;2: CD008009.). However, the authors of one systematic review suggested that participation interventions that increase employee control are unlikely to protect employees from generally poor working conditions (¹⁵15 Egan M, Bambra C, Thomas S, Petticrew M, Whitehead M, Thomson H. The psychosocial and health effects of workplace reorganisation. 1. A systematic review of organizational-level interventions that aim to increase employee control. J Epidemiol Community Health. 2007;61(11):945–54.). For example, two studies of participatory interventions occurring alongside redundancies reported worsening employee health (¹⁵15 Egan M, Bambra C, Thomas S, Petticrew M, Whitehead M, Thomson H. The psychosocial and health effects of workplace reorganisation. 1. A systematic review of organizational-level interventions that aim to increase employee control. J Epidemiol Community Health. 2007;61(11):945–54.). Qualitative evidence suggests that this may be due to job insecurity and communication barriers associated with workplace hierarchies hindering participation interventions (¹⁵15 Egan M, Bambra C, Thomas S, Petticrew M, Whitehead M, Thomson H. The psychosocial and health effects of workplace reorganisation. 1. A systematic review of organizational-level interventions that aim to increase employee control. J Epidemiol Community Health. 2007;61(11):945–54.).

For task restructuring interventions, change in the level of control tended to be a more important factor than change in support (¹²12 Bambra C, Egan M, Thomas S, Petticrew M, Whitehead M. The psychosocial and health effects of workplace reorganisation. 2. A systematic review of task restructuring interventions. J Epidemiol Community Health. 2007;61(12):1028–37.). In all but one study, interventions that increased support while demands were increased and control decreased still reported adverse health consequences (¹²12 Bambra C, Egan M, Thomas S, Petticrew M, Whitehead M. The psychosocial and health effects of workplace reorganisation. 2. A systematic review of task restructuring interventions. J Epidemiol Community Health. 2007;61(12):1028–37.).

The motivation for implementation of the intervention was also very important. Studies in which the motivation for implementing the intervention was employee well-being tended to have more positive psychosocial, health, and work–life balance effects, whereas the effects of those that were the most overtly driven by economics (e.g., fixed-term contracts, involuntary part-time employment, etc.) were negative or negligible in relation to health outcomes (¹²12 Bambra C, Egan M, Thomas S, Petticrew M, Whitehead M. The psychosocial and health effects of workplace reorganisation. 2. A systematic review of task restructuring interventions. J Epidemiol Community Health. 2007;61(12):1028–37., ¹³13 Bambra C, Whitehead M, Sowden A, Akers J, Petticrew M. “A hard day’s night?” The effects of Compressed Working Week interventions on the health and work–life balance of shift workers: a systematic review. J Epidemiol Community Health. 2008;62(9):764–77., ¹⁶16 Joyce K, Pabayo R, Critchley JA, Bambra C. Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database Syst Rev. 2010;2: CD008009.). This included task restructuring interventions (¹²12 Bambra C, Egan M, Thomas S, Petticrew M, Whitehead M. The psychosocial and health effects of workplace reorganisation. 2. A systematic review of task restructuring interventions. J Epidemiol Community Health. 2007;61(12):1028–37.); compressed working week (CWW) interventions (¹³13 Bambra C, Whitehead M, Sowden A, Akers J, Petticrew M. “A hard day’s night?” The effects of Compressed Working Week interventions on the health and work–life balance of shift workers: a systematic review. J Epidemiol Community Health. 2008;62(9):764–77.); and flexible work interventions such as self-scheduling or gradual/partial retirement (¹⁶16 Joyce K, Pabayo R, Critchley JA, Bambra C. Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database Syst Rev. 2010;2: CD008009.).

While precarious employment can take many forms, evidence from two low-quality systematic reviews showed that downsizing/restructuring, temporary work, and outsourcing/home-based work in particular had negative effects on workers’ health, especially in developed countries (⁷7 Quinlan M, Mayhew C, Bohle P. The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv. 2001;31(2):335–414., ²³23 Westgaard RH, Winkel J. Occupational musculoskeletal and mental health: significance of rationalization and opportunities to create sustainable production systems—a systematic review. Appl Ergon. 2011;42(2):261–96.). It was hypothesized by the authors of one of the systematic reviews that, compared to their more secure counterparts, workers in many precarious jobs are subject to high demands / low rewards and have limited decision latitude, even in the case of self-employed and home-based workers (⁷7 Quinlan M, Mayhew C, Bohle P. The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv. 2001;31(2):335–414.). Possible reasons for the negative impacts on health include 1) economic and reward pressures on precarious workers; 2) the association of precarious employment with more disorganized work processes or settings (inadequate supervision, training etc.); and 3) inadequacy in regulation or compliance practices (⁷7 Quinlan M, Mayhew C, Bohle P. The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv. 2001;31(2):335–414.). This is likely to be an even bigger problem in developing countries where the regulatory regimes are less strong.

Strengths and limitations

A key strength of this overview was the use of high-quality systematic review methodology (²⁷27 Higgins JP, Green S, editors. Cochrane handbook for systematic reviews of interventions. Version 5.1.0 [updated March 2011]. London: The Cochrane Collaboration; 2011. Available from: www.handbook.cochrane.org
www.handbook.cochrane.org... ). Publication bias could not be assessed quantitatively in this overview because the authors were unable to conduct a meta-analysis and no clear methods are available for assessing publication bias qualitatively (²⁸28 Song F, Parekh S, Hooper L, Loke YK, Ryder J, Sutton AJ, et al. Dissemination and publication of research findings: an updated review of related biases. Health Technol Assess. 2010;14(8):iii, ix–xi, 1–193.). The quality of the included systematic reviews was generally good, with the majority (11/14) receiving a score of medium to high.

One limitation of this overview was that the included interventions were limited to systematic reviews and economic evaluations, even if primary studies were available. Furthermore, to be included in the overview, a systematic review had to report health outcomes, precluding systematic reviews that only reported changes in environmental, economic, or peace and security outcomes.

Another limitation was the lack of primary studies in developing countries, which restricted the generalizability of the overview to developed countries. Also, only primary studies in the public domain were locatable (the majority of commercial studies were not). Finally, as noted by several of the authors of the systematic reviews included in this overview, the interventions tested in primary studies were not always well described, which made it difficult to fully understand important details about the intervention that was delivered (e.g., whether the employees or managers were supportive of the intervention (¹²12 Bambra C, Egan M, Thomas S, Petticrew M, Whitehead M. The psychosocial and health effects of workplace reorganisation. 2. A systematic review of task restructuring interventions. J Epidemiol Community Health. 2007;61(12):1028–37.) and whether the intervention was delivered as intended (¹⁵15 Egan M, Bambra C, Thomas S, Petticrew M, Whitehead M, Thomson H. The psychosocial and health effects of workplace reorganisation. 1. A systematic review of organizational-level interventions that aim to increase employee control. J Epidemiol Community Health. 2007;61(11):945–54.)). These limitations have been taken into account when presenting and interpreting the results of the systematic reviews.

Implications for policy

Interventions that increase workers’ autonomy or decision latitude and lead to greater alignment between employee needs and the work environment are likely to increase job satisfaction and be good for the work–life balance and health of the worker (¹⁶16 Joyce K, Pabayo R, Critchley JA, Bambra C. Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database Syst Rev. 2010;2: CD008009.). In contrast, the effects of employer-oriented forms of flexibility, such as casual employment and labor hire, are likely to play out differently, with the worker lacking job security, protection, and choice and control (²⁹29 Employment Conditions Knowledge Network. Employment conditions and health inequalities. Final Report to the WHO Commission on Social Determinants of Health. Geneva: World Health Organization; 2007. Available from: http://www.who.int/social_determinants/resources/articles/emconet_who_report.pdf
http://www.who.int/social_determinants/r... ). Thus, certain types of worker-oriented flexible working arrangements represent a plausible means through which policy-makers and employers can promote healthier workplaces and improve work practices (¹⁶16 Joyce K, Pabayo R, Critchley JA, Bambra C. Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database Syst Rev. 2010;2: CD008009.). Policy-makers should also promote and support further research in the areas where gaps were found (described in more detail below), especially in developing countries and for interventions in the informal sector.

Implications for research

More research is needed on the intervention types for which no systematic reviews or economic evaluations were found. This might require more primary studies (until a systematic review is attempted it is difficult to determine if this is necessary). Based on the systematic reviews that were conducted it is clear that primary studies in the health sector (preferably with an appropriate control group) are needed in the following areas: 1) flexible working interventions—teleworking, annualized hours, job sharing; 2) interventions in developing / low- middle-income countries; and 3) interventions in the informal sector. This research must be rigorous and well designed, with credible control groups and objective outcome measures, and must 1) measure, where possible, the organizational or economic effects of the intervention, as well as the health outcomes, and the impact on health inequalities; 2) describe the background and motivation for the intervention (i.e., the study context) as well as details on how the intervention was delivered and the extent to which workers and managers supported the arrangements; 3) include a process evaluation, to ensure the intervention is implemented as intended (i.e., ensure the fidelity of the intervention) and that it does not have unintended consequences; 4) include long-term measures (12 months or more), to measure the sustainability of the results; and 5) assess the cost-effectiveness of the interventions. Where multiple interventions are studied, the research design must allow for the measurement of the relative impacts of each intervention studied.

In the case of precarious employment, a new, high-quality systematic review would be helpful to overcome the limitations of the three low-quality systematic reviews already conducted (⁷7 Quinlan M, Mayhew C, Bohle P. The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv. 2001;31(2):335–414., ¹⁷17 Kim IH, Muntaner C, Vahid Shahidi F, Vives A, Vanroelen C, Benach J. Welfare states, flexible employment, and health: a critical review. Health Policy. 2012;104(2):99–127., ²³23 Westgaard RH, Winkel J. Occupational musculoskeletal and mental health: significance of rationalization and opportunities to create sustainable production systems—a systematic review. Appl Ergon. 2011;42(2):261–96.). This is particularly important for developing countries, where precarious employment has significant implications for national economies and workers. This type of systematic review should take advantage of the large number of studies in this area and include not only a meta-analysis but also a meta-regression to determine the factors that affect the relationship between precarious employment and health (e.g., gender, type of precarious employment, job security, welfare state regime, etc.).

Conclusions

What is needed now is careful implementation in health sector workplaces of interventions that are likely to have positive impacts. In turn, the implementation of these interventions must be carefully evaluated, including possible adverse impacts. Well-evaluated implementation of the interventions (including those at the pilot-study stage) will contribute to the evidence base and inform future action. Interventions with negative health impacts should be withdrawn from practice (through regulation, where possible). If use of these interventions is necessary, for other reasons, considerable care should be taken to ensure an appropriate balance between business needs and human health and well-being.

Acknowledgments

The authors thank the two reviewers who critically reviewed an earlier and longer version of this manuscript and provided very helpful comments.

Funding

This work was funded by PAHO. Apart from the input of the two PAHO authors (EC and LG), the funders did not influence the methods or content of the overview.

Conflicts of interest

None.

Disclaimer

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH or the Pan American Health Organization (PAHO).

REFERENCES

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